HomeMy WebLinkAbout0073 HOLLY HILL ROAD - Health ' � r 13 Holly �
Hill Road, Centerville
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TOWN OF BARNSTABLE
LOCATION v / Al, SEWAGE #
VILLAGE AG—W,, i. ASSESSOR'S MAP & LOT /w D 9 B,
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY /V®® /
LEACHING FACILITY: (type) A-;"AV � ����� (size)
NO. OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland d L aching Facility- If an wetlands exist
within 300 e f a facility) Feet
Furnished
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DATE: 5/18/02
PROPERTY ADDRESS: 73 Holly Hill Road
- Centerville ,Mass .
- ----------------------
02632
------------------------
On the above date, I Inspected the septic system at the abo e address..
VED
This system consists of the following:
JUN 4 4 2002
1 . 1-1000 gallon septic tank .
2 . 1-1000 gallon precast leaching pit . ( 6 ' 1j10 ' ) TOWN OFBARNSTABLE
HEALTH DEPT.
Based on my Inspection, I certify the following conditions:
3 . This is a title five septic system . ( 78 Code ) `
4 . The septic system is in proper working order I Q
at the present time . MAP V
5. Pumped the septic tank at time of inspection . Heavy scum
and solids layers were present . PARCEL .
6 . Waste water is 25" below the invert pipe of the LOT
leaching pit .
SIGNATURE:�
Name :_�_�._
Company ; Joseph_P _ Macomber_& Son , Inc ,
Address ; Box 66
--Centerville , Ma_- 02632-0066
Phone:--- 508_775-3338
--- --------------
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
JOSEPH P. MACOMUtl , & SON, INC,
Tanks•Cesspools•Leachflelds
Pumped & Installed
Town Sewer Connectlons
P.O. Box 66 Centerville, MA 02632-0066
775.3338 775.6412
COMMONWEALTH OF MASSACHUSETTS
r EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
r
TITLE 5
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 73 Holly Hill Road
entervi e , ass .
Owner's Name: Barry Slater
Owner's Address: 23124 Marshland BLVD
Estero Florida 33928
Date of Inspection: 5/18/0 2
Name of Inspector: (please print) Joseph P .Macomber Jr .
Company Name:J. P .Macomber & Son Inc .
Mailing Address: Box 66
Centerville .Mass . 02632
Telephone Number:508-775-3338
CERTIFICATION STATEMENT
I certify that 1 have personally inspected the sewage disposal system at this address and that the information reported
below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. 1 am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
l//Passes
_ Conditionally Passes
_ Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: c Date:
The system inspector shall submit acopy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. if the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page I
f
Page 2 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE
G DISPOSAL SYSTEM INS
PECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 73 Holly Hill Road
Centerville Mass .
Owner: Barry Slater
Date of Inspection:
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A.CEstem Passes;
4�d I h4m ��
formati�nyy
hich indicates that any of the failure criteria described in 3 10 CMR
15.303ist. ailure criteria not evaluated are indicated below.
Comments:
The septic system is in proper working order at the
present time .
B. System Conditionally Passes:/�
One or more system components as described in the "Conditional Pass" section need to be replaced or
repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass.
Answer yes, no or not determined (Y,N,ND) in the for the following statements. If."not determined" please
46 The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
'A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
/t#we—Observation of sewage backup or break out or high static water level in th distribution box ue to broken or
obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of Health):
_broken pipe(s)are replaced
—obstruction is removed
ND explain:
2
Page 3 of I 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 73 Holly Hill Road
Centerville .Mass .
Owner: Barry Slater
Date of Inspection: 5/18/0 2
C. Further Evaluation is Required by the Board of Health:
A,10 Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the
system is not functioning in a manner which will protect public health,safety and the environment:
Ak)Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health (and Public Water Supplier, if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
-60 The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
/UD The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply.
Ald The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
A) The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supple well". Method used to determine distance
"This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
3
Page 4 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 73 Holly Hill Road
Centerville ,Mass .
Owner: Barry Slater
Date of Inspection: 5 18 02
D. System Failure Criteria applicable to all systems:
You must indicate "yes" or"no" to each of the following for all inspections:
Yes ?�'o/
_ 1 ackup of sewage into faciliny or system component due to overloaded or clogeed SAS or cesspool
: Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
Static liquid level in y�e distribution box bove outlet invert due to an overloaded or clogged SAS or
�cesspool G--Jt/"�
/�-iquid depth in eefspeel is less than 6"below invert or available volume is less than ''A day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe($). Number
/of times pumped _j_.
Y/Any portion of the SAS, cesspool or privy is below high ground water elevation.
!/ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
. / Any ponion of a cesspool or privy is within a Zone I of a public well,
!4--* �y portion of a cesspool or privy is within 50 feet of a private water supply well.
!/Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet.from a private water
supply well with no acceptable water quality analysis. ITbis system passes if the well water analysis,
performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this forma
�0 (Yes'No) The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15 303, therefore the system fails. The system owner should contact the Board e.
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design now of 10,000 gpd to 15,000
gpd.
You must indicate either yes"or"no" to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
�e s no
_ the system is within 400 feet of a surface drinking water supply
,
the ystem is within 200 feet of a tributary to a surface drinking water supply
the s stem is located in a nitro en sensitive area interim Wellhead Protection Area— IWPA a— _ Y g (_ ) or a mapped
Zone 11 of a public water supply well
If,vou have answered "yes" to any question in Section E the system is considered a significant threat, or answered
",es" in Section D above the large system has failed. The owner or operator of any large system considered a
s:entficant threat under Section E or failed under Section D shall upgrade the system in accordance with 3 10 CMR
5 304 The system owner should contact the appropriate regional office of the Department.
4
Page 5 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 73 Holly Hill Road
Centerville ,Mass .
Owner: Barry Slater
Date of Inspection: 5/18/0 2
Check if the following have been done. You trust indicate"yes"or"no"as to each of the following:
Yes No/
Pumping information was provided by the owner, occupant, or Board of Health
— ZWere any of the system components pumped out in the previous two weeks?
Has the system received normal flows in the previous two week period?
Have large volumes of water been introduced to the system recently or as part of this inspection?
Were as built plans of the system obtained and examined?(If they were not available note as N/A)
_ Was the facility or dwelling inspected for signs of sewage back up?
Was the site inspected for signs of break out ?
Were all system components,�luding the SAS, located on site
Were the septic tank manholes uncovered, opened,and the interior of the tank inspected for the condition
of the baffles or tees, material of construction,dimensions, depth of liquid, depth of sludge and depth of scum ?
ZWas the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil stem Absorption S SAS on the site has been determined based on:
P Y (SAS)
Yes no /
t/ Existing information. For example, a plan at the Board of Health.
Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) [310 CMR 15.302(3)(b)]
s
5
Page 6 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 73 Holly Hill Road
Centervi e , ass .
Owner: Barry Slater
Date of Inspection: 5 18 02
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x# of bedrooms): 0*04M
Number of current residents: n _
Does residence have a garbage grinder(yes or no): 416
Is laundry on a separate sewage system (yes or no):. /O [if yes separate inspection required]
Laundry system inspected(yes or no): j
Seasonal use: (yes or no):41V
Water meter readings, if available (last 2 years usage(gpd)): 2000-110, 000- gall6ns=301 . 37 GPD
Sump pump(yes or no):40 =1— 82 , —gallons=224 . 77 GPD
Last date of occupancy: �&V M
COMM ERCIAL/INDUSTRIAL
Type of establishment: ,to
Design flow(based on 310 CMR 15.203): 41A gpd
Basis of design flow(seats/persons/sgR,etc
Grease trap present(yes or no): /
Industrial waste holding tank present(yes or no):iG�/9
Non-sanitary waste discharged to the Title 5 system(yes or no):&4
Water meter readings, if available: .4114
Last date of occupancy/use: A(A
OTHER(describe): X14
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as part of the inspection(yes or no): _5
If yes, volume pumped:16160 gallons -- How was quantity pumped determined?XZW' Jal l'�j
Reason for pumping: Heavy scum & solids lavers were present .
TY C OF SYSTEM
Septic tank, dise4batien box, soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no)(if yes, attach previous inspection records, if any)
_ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
�v Tight tank �Attach a copy of the DEP approval
�A)Other(describe):
Apppr'oximate a-e of all components, date installed (if known)and source of information:
N &� 192s-
Were sewage odors detected when arriving at the site(yes or no): X-e
6
Page 7 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 73 Holly Hill Road
Centerville ,Ma.as ,
Owner: Barry Slater
Date of Inspection: 5/18/0 2
BUILDING SEWER(locate on site plan)
Depth below grade: bl
Materials of construction:/112cast iron Z40 PVC, /d other(explain): AO
Distance from private water supply well or suction line:
Comments (on condition of joints, venting, evidence of leakage, etc.):
Joints appear tight . No evidence of leakage . The system is
vented through the house vents .
SEPTIC TANK: Y (locate on site plan) J9e9
Depth below grade: /;r
Material of construction:/concretex)a metaIA/e fiberglass polyethylene
/LV other(explain) AO
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or noWO (attach a copy of
certificate) ��
Dimensions: �� *1V I A s "" 1
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness: _1
Distance from top of scum to top of outlet tee or baffle: Q
Distance from bottom of scum to bottom of outlet tee or baffle: S�
Howwere dimensions determined: Pumped tank at time of inspection .
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
Pump the septic tank every 2-3 years Inlet & ou ; et tees
are present . The tank is structurally sound and shows no
evidence of leakage .
GREASE TRAP&{ (locate on site plan)
Depth below grade:
Material of construction;,Aconcrete,,J metaI40 fiberglass,aJ�olyethylene.ifiother
(explain): /Ul!
Dimensions: 011
Scum thickness: /f i
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:_ t�
Date of last pumping: /V�v
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
Grease trap is not present .
7
Page 8 of 1 I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 73 Holly Hill Road
Centerville , Mass .
Owner: Barry Slater
Date of Inspection: S/18/0 2
TIGHT or HOLDING TANKe%(tank must be pumped at time of inspect ion)(locate on site plan)
Depth below grade: 4114
Material of construction: concrete metal 414 fiberglass,±/, Polyethylene 44 other(explain):
Dimensions: A
Capacity: A)11 _gallons
Design Flow: 141W gallons/day
Alarm present(yes or no): i(1A
Alarm level: 414 Alarm in working order(yes or no): y�
Date of last pumping: it14
Comments(condition of alarm and float switches, etc.):
Tight or holding tanks are not present
DISTRIBUTION BOX (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: A*
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of
leakage into or out of box, etc.):
Distribution box is not nrPsant
PUMP CHAMBER!✓Z/C (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.):
Pump chamber is not nresPnt _
8
Page 9 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:73 Holly Hill Road
e n t e r v i e , ass .
Owner: Barry S ater
Date of Inspection: 5 18 02
SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required)
1-1000 gallon precast leaching pit . ( 6 ` X10'
If SAS not located explain why:
Located see page 10
i
ype
leaching pits. number:
O leaching chambers, number:
A10 leaching galleries, number:
2j leaching trenches, number, length: (�
A10 leaching fields, number, dimensions:
iL overflow cesspool, number: 0) ,� � ��L >
innovative/alternative system Type/name of technology: /i ,tl/,,Cr, %, /
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,
etc.):
Loamy sand to medium sand to fine sand No signs of hydraulic
failure or Ponding . Soils are dry Vegetation is normal
CESSPOOLS41sth'• (cesspool must be pumped as pan of inspection)(locate on site plan)
'umber and configuration: Q
Depth —top of liquid to inlet invert: AIA
Depth of solids layer: ItI4
Depth of scum laver
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no): .f,
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
Ces-pools are not present _
PRIVY44,'e—(locate on site plan)
Materials of construction: /Ui4
Dimensions:
Depth of solids:
Corments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
_Pri ArV i c not present
9
• Page 10 of I I
OFFJCIA.L INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Properry Address: 73 Holly Hill Road
L nterville Mass .
Owocr: Barry Slater
Dslc o( Inspcclioo: 5 18 02
SKETCH OF SEWACE DISPOSAL SYSTEM
PTovioc s sketch of the scwa4c disposal system including tics to el least two permanent reference landmarks of
ocnc"ukt. Loc+ie ill well$ within 100 feet. Locate where public water supply enters the bvilding.
• IIII
3
T
♦ i / � O
10
+ Page I I of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 73 Holly Hill Road
Centerville , Mass .
Owner: Barry Slater
Date of Inspection: 5 18/02
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water D feet
Please indicate (check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record - If checked, date of design plan reviewed: -yA
bserved site(a urting properEVobservation hole within 150 feet of SAS)
40 Checked with local Board of ealth-explain: AO
ff Checked with local excavators, installe�r (atjach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Used ; Gahrety & Miller Model . 12/16/94 Ground water levels 'above sea level .
USGS ; Observation well data June 1992
USGS : Technical bulletin - 92—Q00-1 plate #2 Jnnvary 1Q92
Annual ranges pgruu round water elevat ' onc
Leaching
Pit 'cc(
'31 t
Croundwater Feet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Frimpter Method
Therefore, the vertical separation distance between the bottom `A
Of the leaching pit and the adjusted groundwater table is
feet.
11
`.,rr�r„-,..ra—.-.•,-..,r. n,-n.i..rr�.,>at...-,-r..,.-r-.4.,.,rr-er,,,.,nv„s-�re�r+s,
1 Barnstable rn� � • �••'
TOWN OF BOARD OF HEALTH 1
0 _--T '--'--SIII)SURFACE SEHAGR DISPOSAL SYSTEM INSPECTION FORM - PART D .- CERTIFICATION
..—rrr•r•�. .-..
-TYPE OR PRINT CI.EARLY-
PROPERTY INSPECTED
STREET ADDRESS 73 Holly Hill Raod Centerville ,Mass . '
ASSESSORS MAP , BLOCK AND PARCEL # 188/98
OWNER' s NAME Barry Slater
PART D - CERTIFICATION I
NAME OF INSPECTOR Joseph P.Macomber Jr .
COMPANY NAME J. P.Macomber & Son Ins''.`
COMPANY ADDRESS Box 66 Centerville Mass . 02632
Street Town or Clty State LIP
COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX (508 790 -1578
R
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposaj system at
this address and that t)Ie information reported is true , accurate , and
omplete as of the time ofeinspection . The inspection was performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems ,
Check one :
Y ` System PASSED
The inspection which I have conducted has not found any 'information
which indicates that the system fails to adequately protect public
health or the environment as defined in 310 CMR 15 . 303 , Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form .
System FAILED*
The inspection which I hav ilcted has found that the system fails to
Protect the public health and the environment in accordance with Title
5 , 310 CMR 15 , 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form ,
Inspector Signature e Date ��`a�
ne copy of this cer .ification must be provided to the OWNER, the BUYER
a
where applicable ) Bind the BOARD OF HHAL1'll.
* If the inspection FAILED, the owner or"O'o erator shall upgrade
he aYste
within one year of the date of the inspection , unless allowed ortrequiredm
otherwise as provided in 310 CPIR 15 . 305 ,
partd .doc
1A,,t�••1j THE COMMONWEALTH OF MASSACHUSETTS
tiD 4- BOARD F,��.ATH.,
n - - . ... ..OF
�3 . ^-(t App iration -fix Iispuiitt1 Works Ton.15trurtion Vrrmft
Application is hereby made_�°r Pit t�/�Cpj�struct ) epair ( ) an Individual Sewage Disposal
System at: cog '�i "`� �T'G` d- K-G�
...... . .....�....... ...... �..-----..... �...._------.. ..z6 ---------------------------------
Locatiod r s u or Lot No.
lN '` '�'�► 6C-c . � 6---•-7....q-• ......... .....
• Owne Address
Installer Address
Q Type of Building Size Lot ti.1.7j.70--_-Sq. feet
v Dwelling—No. of Bedroom / '3 ----------------Expansion �Attic ( ) Garbage Grinder ( )
Other—Type of Building .___. !. Jf��___. No. of persons..._.................... Showers ( ) — Cafeteria ( )
dOther fixtures .-----Z+----�-�="�--•--•-----------•----------------------------------------•------------•-------
W Design Flow................... ` __________ Mons per person per day. Total daily flow_--._-______ __ ____...__...__gallons.
WSeptic Tank V Liquid capacity/ llons Length---------------- Width................ Diamet r-----.---_.._-_ Depth___._._-_-._.---
x Disposal Trench—No- --------•--•-------- Widt i- o� tli----- -eZ 1 thing area--------------------sq. ft.
Seepage Pit No........�__________ Diameter_. ....-----------
i t .... ........... Total leaching area.-__.___----____-sq. it.
Other Distribution ox ,�'- 7J-
zb ( ) Dosing tank ( ) 0�-
aPercolation Test Results Performed by----------------------------------------------------- v----.�---�-�ate------------------------------------....
Test Pit No. 1----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water_---.__-_-.-_-----.._-
r14 Test Pit No. 2----------------minutes per inch Depth of Test Pit.................... Depth to ground
x
-- ---- f water-..--._-_-_.-..-___.---_-.
----------Y ---------- ------
O _ ---------
Description --------------------------------------------------------------------------------------------------------------------Wx ------------------------------------- - •------------ ------------------------------------------------------------------ -----------------------------------------------------------------------
-
V Nature of Repairs or Alterations—Answer when applicable------------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------••-•---.---•------•-----------•---- --------•---•---------------••--•---••-•-----•-----------------.-----•--------
Agreement':
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed...
$�( `�e l0 Date ....
14 YPI,"S �Application Approved By------------------_ ........................................................................... ----------------•--•--------------------
Date
Application Disapproved for the following reasons:---•--------------•-------•-------------------...------•-----------------------------------------------------•--
---••-••-••--••--•-----••-•------•--•------------------------------------••-•-•-••-••----•-•-•------------••--------•-•--•••• .......................... ------•--------•-••-••-•-----------••-••-••--•-
/ ate
Permit No... Issued ( = �C -`--
-----------
Date
NO..............? .................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD TF HEA TH
�...... --...OF......... ..... - .... . ........ - .......
Appliratiuu -fur IN-4purittl Works Tutu5trurtiuu Putuit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
v . f t. �u• �. ...... f (. �..� ..
Location'Address or Lot No.
.....................................� 1:_c �. ' ' r �''= --> r U <,,• r
----- - ..--•- ,
Owner 1, Address J ,
Installer Address U Type of Building r Size Lot.�_�._./._�..2 U.O_.._.Sq. feet
.-� Dwelling—No. of Bedrooms,----------3____________________________Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building _... No. of persons------- ................. Showers ( ) — Cafeteria ( )
d Other fixtures --•-- ��� 1= 71c.�------- •-_--------------
---------------------------
W Desi n"Flow.. ............. 1llons per person per day. Total daily flow-_-__ ��
g ----Imo'------------ --�--�j P P P Y• Y ----...�----------------------------gallons.
P4 Septic Tank�—Liquid capacity) allons Length---------------- Width...-----....... Diamet r--------------_ Depth-----•----------
x Disposal Trench—No_____________________ Widt i__..--_--..-.-._--_�o �n�gtl�------ t- ��hing area--------------------sq. ft.
Seepage Pit No......../____------ Diameter... 1_.....��pth`Hel(�i6 iffl'e - --- ------------ Total leaching area..................sq. ft.
Distribution 0 - f" � - / 7j
z OtherD st ibution box ( ) Dosing tank ( ) 6
t 1Z�J
Percolation Test Results Performed bY-•------ ------------••-•-----------•......................---••-......•�ate---------------------------------------.
Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water..--_..-_-__-._.--.--..-
(Ll Test Pit No. 2----------------minutes per inch Depth of Test Pit.................... Depth to ground water-_.--.-___---____-__-. -
P4 -------
O Description of Soil..._____.__ � 1 G .. �u.f Z - /2
------••. ".............. .............. --- ------
U ------------- --------- ---- � � ��1
W
x ------------------------- -----------------------------------------------------------------------------------------------------------------------------------------------------•--------------••-••-----
V Nature of Repairs or Alterations—Answer when applicable.-...-------------I--------------------_---------------------- ..........................
-----•--------------------------------------- -------------------------------------••---------------------------------------------•-------------•-----•--------------------------- ----------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed...r r .� r L L , .. = f... f
------r---f--fG-'--'-,--••-•-----••-•--• -- --
.� /• e.. ��+-r.�- r .''-, i r /_�_ Date
ApplicationApproved By----------------------------------- ......................................................... --------- --------------------------
Date
Application Disapproved for the following reasons:....-----•----•-----------------•-_.----•--•---••---------------•-••---------------.--•---•----•-•--•-----------
..........-•--•-•-•--•--------------------•-------....---------•-•---•---•--•-•-•---....------•---------------------•...••••••-•••--•-•--•------••-•---•••--------------••-••-•---•--••-•-----•••-------
Date
PermitNo........................................................ Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O HEALTH
/` -✓YI............OF......... . . ...C[ /.lA...................................................
Trrtifiratr of 0.11,11mphatta
TIFIS TO CER TTf Y, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
nstaller
at.. ...4):--- L, -- -- 42—
-
has been installed in accordance with the provisions of _-�ilgle XI of The S to Sanitary Code as described in the
application for Disposal Works Construction Permit ------------------ dated...-`/-_"_e?..._..7S_'...._.__--•--------
THE ISSUANCE OF THIS CERTIFICATE SHALL. NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEA TH
5). r lm..........O F....... ;J...G G .` ...
2 s y ---------------------------
No......................... FEE.. / .............
ui Workii#nmitrurtion Vrrmit
Permission is hereby granted =G i
to Cons rut (�) or aVair ) an In ' id ail Sewage ispo,al/S stem ��
at No — .. -C G�---2
... m!:� - --- ---
Street 7
as shown on the application for Disposal Works Construction �mit o�_ ... ...... Dated... --_Z_ .._.._`..................
. ....
Board of Healt
DATE................................................................................ U
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
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12.46
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